1. Caller contact

Never sent to a partner firm until the partner accepts the case.

First Name

Last Name

Phone *

Email

Language

English

Spanish

Other

2. Client's story

In the caller's words: what happened, when, and what they want.

Client's story

3. Basics and screening

County where it happened

Date of incident

Already has a lawyer?

Yes

No

Unsure

Signed anything or settled?

Yes

No

Unsure

Statute of limitations concern?

Yes

No

Pay type

Hourly

Salary

Commission

Not Working

Pay rate

4. Case type

Check all that apply. The matching section(s) will open below.

Case type *

Declined PI

Medical Malpractice

Workers' Comp

Other

5a. Declined PI

Accident type

Why ALF is declining

Injuries and treatment so far

Insurance information

Police report?

Yes

No

Unsure

Other PI details

5b. Medical malpractice

Provider or facility

Date of treatment

What went wrong

Resulting injury

Other med-mal details

5c. Workers' comp

Employer

Job title

Date of injury

Reported to employer?

Yes

No

Unsure

How the injury happened

Other workers' comp details

6. Outcome

Screening result *

Qualified

Not Qualified

Attorney Review

Referral consent script

Read to the caller: "We aren't able to take your case ourselves, but we work with trusted law firms that may be able to help. May we share your case details with one of them? There is no cost to you for the referral." / "No podemos tomar su caso, pero trabajamos con otros bufetes de confianza que podrían ayudarle. ¿Nos permite compartir los detalles de su caso con uno de ellos? La referencia no tiene ningún costo para usted."

Client agrees to referral?

Yes

No

Staff notes

7. Referral firm (optional)

Only if the receiving firm is already chosen. Leave blank and Ed will pick the firm.

Firm name

Attorney name

Firm email (main recipient)

CC emails (comma-separated)

Firm phone

Referral fee %